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SAN JOAQUIN <br /> <br />Environmental Health Department <br />COUNTY <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />To be completed by APPLICANT <br />Business Name TA cn co.yi (-=-/uo.s Lic. Plate # L-1 LA) Z5 ,--11 <br />Owner/Operator Name 1,-A 00C-Lf- AC'ci OC-VA- t JOD <br />Business Mailing Address (9,35 cl /0 <br />City 1-‹ A C, State (A zip°vj371 Bus. ph.clac -5go -21,3,-)-Alt. Ph. <br />I, 1,A1\C LL-k) PIC,C1KM:;-(iPr , hereby state that the above information is current, true and correct to <br />the best of my knowledge and agree to utilize my approved commissary in accordance with California Health & <br />Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br />commissary is discontinue the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. <br />Signature <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name UUjo e(176--,rou h cHurki.: FA# <br />Address Oil S- Ai 5J. BUS. Phone 2(11 -2 --.5 (-11 cc <br />City fl OCI(1011,-) Zip S2 0 Owner/Operator QS t a <br />Check all appropriate services provided: <br />Date \ IJ,:)-U 69 (-1 <br />la Wastewater disposal <br />tp; Solid waste disposal <br />1,3(Hot & Cold water for cleaning <br />O Stire dry food/supplies <br />I, (t<.16< <br />correct to the best of my knowledge, <br />operator fails to comply with th <br />commissary owner s II <br />Signature <br />, hereby state that the information I have provided is current, true and <br />and meets the California Health & Safety Code requirements. If the food facility <br />ditions of this agreement, or if this agreement is modified or cancelled, the <br />immediately. <br /> Date \ <br />3-compartment sink <br />Electrical hook-ups <br />Food preparation <br />X Toilet and handwashing <br />Store refrigerated food <br />Potable water <br />Overnight parking X Vehicle wash <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in County. The above food facility meets the <br />commissary requirements in California Health & Safety Code. The above checked services are available at the <br />above commissary. Please notify EHD if the status of their operating permit changes. <br />RENS Signature Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />F050,9 22"1